RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

KARNATAKA, BANGALORE.

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1 Name of the candidate and

address

Dr. SYEDA SIDDIQUA BANU

P.G. IN GENERAL SURGERY,

DEPARTMENT OF GENERAL SURGERY,

VIMS, BELLARY.

2 Name of the Institution VIJAYANAGARA INSTITUTE OF

MEDICAL SCIENCES, BELLARY.

3 Course of the study and subject M.S IN GENERAL SURGERY

4 Date of admission to the course 01.06.2012

5 Title of the topic A CLINICAL SYUDY OF “INTUSSUSCEPTION” IN

CHILDREN AT VIMS, BELLARY

6 BRIEF RESUME OF INTENDED WORK

6.1. Need for study

Intussusception is one of the most common pediatric emergencies.

“Intussusception is defined as the telescoping of one segment of bowel (intussusceptum) into

another, usually most distal segment of bowel (intussuscipiens).

Patients of intussusception may progress to bowel obstruction and death if the intussusception is

not reduced.

As the mesentery of the proximal bowel is drawn into the distal bowel, it is compressed, which

results in venous obstruction and oedema of bowel wall. If reduction of the intussusception does not

occur arterial insufficiency and bowel wall necrosis follows. Although spontaneous reduction occurs,

the natural history of the intussusception is to progress to a fatal outcome as a result of sepsis, unless

the condition is recognised and appropriately treated. A small proportion of patients may have a

spontaneous reduction of intussusception before the diagnosis is confirmed by radiological or

surgical techniques.

In 1953 Gross stated: “There are few illnesses in which the clinical history and physical

findings are more suggestive of the correct diagnosis.”(1)

At present, diagnosis and treatment is a combined effort among the pediatrician, the pediatric

radiologist, and the pediatric surgeon.

Accurate estimates of gender predominance, most common age of presentation, seasonal variation,

lead points, and modes of conservative or surgical management of intussusception are not available

for most of the developing countries and developed countries.(2)

(WHO/V & B/02.19)

Hence the need for study.

6.2 OBJECTIVES OF THE STUDY

To study the:

Gender predominance

Age of presentation

Seasonal variation

Etiological factors

Lead points

Clinical features

Investigations

Non Operative and Operative measures of management

REVIEW OF LITERATURE: The word intussusception is derived from the Latin

words intus (within) and suscipere (to receive).[3] 

Intussusception was recognized as a disease in the late 1600s in Europe. It was first described by

Paul Barbette of Amsterdam but Hunter provided the first detailed description of intussusception

in 1793.[4] 

Treatment of intussusception at that time included bleeding and quicksilver, to which Hunter

added emetics followed by purgatives , hand bellows to attempt pneumatic reduction per anus

were possibly tried as early as Hippocrates' time.[5] 

In U.S Ravitch popularised the use of barium enema reduction for this problem.His 1959

monograph reviewing all aspects of intussusceptions remains a classic.(6)

In the early 1800s, the first documented descriptions of pneumatic reduction for intussusception

appeared in the medical literature.[7] by Harald Hirschprung.

In 1913, Ladd(8) published the first radiograph of a contrast enema in intussusception.

In 1927, first saline reduction was successfully done in Australia by Hipsley (9).

In 1977, the ultrasonograph pattern of intussusceptions was reported by Burke and Clarke (10) and

the “target” sign of end-on intussusception and the “pseudokidney”appearance of a lateral

intussusception were defined.

Jonathan Hutchison reported the first successful operation for intussusception in a 2 year

child in 1873 (11,12)

6.4 Abstract:

Incidence: Idiopathic intussusception can occur at any age. However the greatest incidence

occurs in infants between ages 5 and 9 months. More than half of the cases occur within first year

of life, and only 10-25% occur after 2 yrs (13,14) of age. The condition has been described in

premature infants and has been postulated as the cause of small bowel artesia in some cases (15)

Gender predominance: Most patients are well nourished , healthy infants, approx two thirds are

boys(13).

Seasonal variation: Variations in incidence have been described in relation to the calendar

months, or to the seasonal pattern. Whereas in tropical zones the seasons were described as either

wet or dry, and referred to as summer, autumn, winter and spring in temperate zones. Seasonal

variability is also related to the peak incidence of admissions of patients with acute gastroenteritis

(2).

In India an increased incidence of intussusception was reported in the summer months.

(WHO/V&B/00.23, 2000). Another study reported an increase in intussusception admissions in

April and May associated with the peak incidence of gastroenteritis (Talwar et al., 1973)

ETIOLOGY:

Idiopathic

Change in diet during weaning.

Upper respiratory tract infection: viral infections like human herpes virus-6, and

adenovirus appeared to co relate with increased risk of intussusceptions(16).

`an association has been found between administration of rota virus vaccine (rota shield)

(17)

Electrolyte derangements associated with various medical conditions can produce

aberrant intestinal motility, leading to enteroenteral intussusception.

Postoperative intussusception: Its a rare postoperative complication, occurring in 0.08-

0.5% of laparotomies

Indwelling catheters : Very rarely, indwelling jejunal catheters can lead to intussusception

by acting as a lead point, which is especially true if the tip of the catheter has been

manipulated or cut so that its surface is not smooth

Miscellaneous : cystic fibrosis, henoch schonlein purpura, haemophilia.

Intussusception may have an identifiable lesion that serves as a lead point, drawing

the proximal bowel into the distal bowel by peristaltic activity.

In approximately 2-12% of children with intussusception, a surgical lead point is

found. Occurrence of surgical lead points increases with age and indicates that the probability of non

operative reduction is highly unlikely. Examples of lead points are as follows:

Meckel’s diverticulum[18] (most common lead point)

Enlarged mesenteric lymph node

Benign or malignant tumours of the mesentery or of the intestine, including lymphoma,

polyps, ganglioneuroma,[19] and hamartomas associated with Peutz-Jeghers

syndrome,Kaposi’s sarcoma(20), Post transplantation lymphoproliferative disorder (PTLD) (21).

Mesenteric or duplication cysts

Submucosal hematomas, which can occur in patients with HSP and coagulation dyscrasias

Ectopic pancreatic and gastric rests

Inverted appendiceal stumps

Sutures and staples along an anastomosis

Intestinal hematomas secondary to abdominal trauma

Foreign body

Hemangioma

Other causes

More than 80% of intussception are ileo-colic. The ileo-ileal, caeco-colic, colo-colic and

jejuno-jejunal varieties occur with increasing rarity(13).

Clinical features:

Cyclical, colicky abdominal pain

Vomiting

“Currant jelly” stools (diarrhea with mucus and blood) or other blood in

stool

Classic triad occurs in about 1/3 of patients; most have 2 of the 3

Palpable abdominal mass, often in right upper quadrant

Dance’s sign: RUQ mass (intussusception) with RLQ empty space

(movement of cecum out of normal position) (22).

Investigations :

Plain abdominal radiographs: abdominal mass, abnormal gas distribution, sparse large bowel

gas, air fluid levels in case of obstruction.

Contrast enema : Barium enema- shows “claw sign” or Coiled spring appearance.

Ultrasonograph : target sign, or pseudokidney sign.

Ct: not routinely done, shows intra luminal mass with layered appearance or fat or both in the

mass or in continuity with the mesenteric fat.

Management:

a)Non surgical: hydrostatic or pneumatic reduction.

Non surgical reduction is an important primary treatment for paediatric intussusception due to its

high success rate and low incidence of complications,a reduction technique has two components;

1) Under usg/fluoroscopy guidance (14,23-25).

2) Air (pneumatic reduction)/barium or saline (hydrostatic reduction) contrast.

Numerous reduction techniques have been mentioned in literature, and many authors have

described the advantages and disadvantages of each technique (14,23-36,37,38).

However Usg guided pneumatic reduction is most commonly preferred and is considered

to be most feasible and effective because it has a success rate of 92% and above (39) and

poses no radiation exposure to either the patient/medical personnel(29-33).

Though fluoroscopy also has a good success rate (14,23-25),its not much used because it uses

ionising radiation, and it may not depict lead points or might lead to residual ileo-ileal

intussusceptions.(28)

b)Surgical: Open or reduction/resection and anastomosis

MATERIALS AND METHODS

7.1.

The patients attending the department of SURGERY and also patients referred from other

departments of combined hospitals of MCH VIMS, Bellary form the subjects for our study.

A written informed consent will be taken from all patients included in the study. A detailed

history-taking, thorough clinical examination will be done for these patients. The data collected will

be entered into a specially designed case record form.

INCLUSION CRITERIA

1.. Patients presenting with clinical features of pain abdomen, vomiting or bleeding per rectum.

2.. Age below 12 yrs.

EXCLUSION CRITERIA

1. Age above 12 yrs.

7.2. a) METHOD OF COLLECTION OF DATA

A written informed consent will be taken from all patients included in the

study. A detailed history-taking, thorough clinical examination will be done

for these patients. The data collected will be entered into a specially

designed case record form.

b) DURATION OF STUDY

The study will be conducted from November 2012 to April 2014.

7.3. DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR

INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER

HUMANS OR ANIMALS?

YES. All the patients included in the study are investigated with

1. Routine blood investigations

(Hb %,BT, CT)

2. Usg abdomen

3. Xray abdomen

7.4 . HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR

INSTITUTION?

YES. Ethical Clearance has been obtained from Institutional Ethical Committee (IEC) of

VIMS, Bellary.

LIST OF REFERENCES:

1. Gross R.E.: Intussusception.  The Surgery of Infancy and childhood, Philadelphia: WB

Saunders; 1953:281.

2. WHO/V&B/02.19 ( www.WHO.int/vaccines.documents/)

3. Hamby L.S., Fowler C.L., Pokorny W.J.: Intussusception.

In: Donnellan W.L., ed. Abdominal Surgery of Infancy and Childhood,

Australia: Harwood; 1996:1.

4. Barbette P.: Oeuvres Chirurgiques et Anatomiques.  Geneva, François Miege, 1674,P 522

5.  McAlister W.H.: Intussusception: Even Hippocrates did not standardize his technique of

enema reduction. Radiology  1998; 206:595.

6. Ravitch MM: Intussusception in Infants and children. Springfield,III, Charles C Thomas,

1959.

7.  McDermott V.G.: Childhood intussusception and approaches to treatment: A historical

review. Pediatr Radiol  1994; 24:153.

8. Ladd WE: Progress in the diagnosis and treatment of intussusception. Boston Med Surg J

168:542, 1913

9. Hipsley PL: Intussusception and its treatment by hydrostatic

pressure: Based on analysis of 100 consecutive cases so treated. Med J

Aust 2:201-201, 1926.

10. Burke LF, Clarke E: Ileocolic intussusception—a case report.

J Clin Ultrasound 5:346-347, 1977

11. Hutchinson J: A successful case of abdominal section for intussusception. Proc R Med Chir

Soc 7:195-198,1873.

12. Ravitch MM (1951) “Jonathan Hutchinson and intussusceptions” Bulletin of the history of

medicine 25(4) : 342-53.

13. Stringer MD, Pablot SM, Brereton RJ: Paediatric intussuscception. Br J Surg 79: 867-876,

1992

14. Guo J, Ma X, Zhou Q: Results of air pressure enema reduction of intususseption: 6,396

cases in 13 yrs. J Paediaric Surg 21: 1201-1203,1986

15. Mooney DP, Steinthorsson G, Shorter NA: Perinatal intussusception in premature infants.

J Paediatric surg 31: 695-697, 1992

16. Lappalainen S, Ylitalo S, Arola A, Halkosalo A, Räsänen S, Vesikari T. Simultaneous

presence of human herpesvirus 6 and adenovirus infections in intestinal intussusception of young

children. Acta Paediatr. Jun 2012;101(6):663-70. 

17. Zanardi LR, Haber P, Mootrey GT, et al. Intussusception among recipients of rotavirus

vaccine: reports to the vaccine adverse event reporting system. Pediatrics. Jun 2001;107(6):E97.

18. Milbrandt K, Sigalet D. Intussusception associated with a Meckel's diverticulum and a

duplication cyst. J Pediatr Surg. Dec 2008;43(12):e21-3. 

19. Soccorso G, Puls F, Richards C, Pringle H, Nour S. A ganglioneuroma of the sigmoid colon

presenting as leading point of intussusception in a child: a case report. J Pediatr Surg. Jan

2009;44(1):e17-20. 

20. Sanni RB, Nandiolo R, Coulibaly Diaoudia MT, Vodi L, Mobiot ML. Acute intussusception

due to intestinal Kaposi's sarcoma in an infant. Afr J Paediatr Surg. Jul-Dec 2009;6(2):131. 

21. Earl TM, Wellen JR, Anderson CD, et al. Small bowel obstruction after pediatric liver

transplantation: the unusual is the usual. J Am Coll Surg. Jan 2011;212(1):62

22. Schwartz's Principles of Surgery/Specific Considerations. MeGraw Hill Text; 1700-1701,

1994..

23. Kirks DR. Air intussusception reduction:the winds of change. Pediatr Radiol 1995;25:89–91.

24. Shiels WE II, Maves DK, Hedlund GL,Kirks DR. Air enema for diagnosis and reduction of

intussusception: clinical experience and pressure correlates. Radiology 1991; 181:169–172.

25. Stein M, Alton DJ, Daneman A. Pneumaticreduction of intussusception: 5-year experience.

Radiology 1992; 183:681–684.

26. McAlister WH. Intussusception: even Hippocrates did not standardize his technique of enema

reduction. Radiology 1998; 206:595–598.

27. del-Pozo G, Albillos JC, Tejedor D, et al. Intussusception in children: current concepts in

diagnosis and enema reduction. RadioGraphics 1999; 19:299–319.

28. Miller SF, Landes AB, Dautenhahn LW, et al. Intussusception: ability of fluoroscopic

images obtained during air enemas to depict lead points and other abnormalities.

Radiology 1995; 197:493–496.

29. Peh WCG, Khong PL, Lam C, et al. Reduction of intussusception in children using

sonographic guidance. AJR Am J Roentgenol 1999; 173:985–988.

30. Woo SK, Kim JS, Suh SJ, Paik TW, Choi SO. Childhood intussusception: US-guided

hydrostatic reduction. Radiology 1992;182:77–80.

31. Kim YG, Choi BI, Yeon KM, Kim CW. Diagnosis and treatment of childhood intussusception

using real-time ultrasonography and saline enema: preliminary report. J Korean Soc Med

Ultrasound 1982;1:66–70.

32. Bolia AA. Case report: diagnosis and hydrostatic reduction of an intussusception

under ultrasound guidance. Clin Radiol 1985; 36:655–657.

33. Yoon CH, Kim HS. Ultrasound guided reduction of childhood intussusception. J Korean

Radiol Soc 1986; 22:788–793.

34. Hadidi AT, Shal NE. Childhood intussusception: a comparative study of nonsurgical

management. J Pediatr Surg 1999;34:304–307.

35. Daneman A, Alton DJ. Intussusception: issues and controversies related to diagnosis and

reduction. Radiol Clin North Am 1996; 34:743–756.

36. Meyer JS, Dangman BC, Buonomo C, Berlin JA. Air and liquid contrast agents in

the management of intussusception: acontrolled, randomized trial. Radiology 1993;

188:507–511.

37. Wang G, Liu XG, Zitsman JL. Nonfluoroscopic reduction of intussusception by air

enema. World J Surg 1995; 19:435–438.

38. Todani T, Sato Y, Watanabe Y, Toki A, Uemura S, Urushihara N. Air reduction

for intussusception in infancy and childhood: ultrasonographic diagnosis and management

without x-ray exposure. Z Kinderchir 1990; 45:222–226.

39. Yoon CH, Kim HJ, Goo HW: Intussusception in children: US-guided pneumatic reduction—

initial experience. Radiology 218:85-88, 2000

9 Signature of the candidate

10 Remarks of the guide

11 11.1. Name and designation of the

Guide

Dr. VIDYADHAR A KINHAL

PROFESSOR & HOD ,

DEPARTMENT OF SURGERY,

VIMS, BELLARY.

11.2. Signature

11.3 Co-guide Dr. SANJEEV B. JOSHI MS MCH (PAED.SURGERY)

ASSOCIATE PROFESSOR,

DEPARTMENT OF SURGERY,

VIMS BELLARY

11.4 Signature

11.5. Head of the Department Dr. VIDYADHAR A KINHAL

PROFESSOR & HOD ,

DEPARTMENT OF SURGERY,

VIMS, BELLARY.

11.6. Signature

12 12.1. Remarks of the Chairman

and Principal

12.2. Signature.

From, Date: Dr.Syeda Siddiqua Banu., Bellary. Post Graduate in General Surgery, Department of Surgery, Vijayanagara Institute of Medical Sciences, Bellary.

To, The Principal, Vijayanagara Institute of Medical Sciences, Bellary.

THROUGH PROPER CHANNEL

Sir, Subject: Submission of registration and forwarding of dissertation topic.

In accordance with the above cited topic, I the undersigned studying in Post Graduate course in M.S. GENERAL SURGERY has been allotted the dissertation topic “A clinical study of intussusception in children at VIMS Bellary” under the guidance of Dr.Vidyadhar A Kinhal, Professor and Head, Department of SURGERY, VIMS, Bellary, and Co-Guide Dr.Sanjeev B. Joshi, Associate professor, Department of SURGERY, VIMS, Bellary. I request you kindly to forward the dissertation topic in the prescribed form for the Rajiv Gandhi University of Health Sciences, Bangalore for Approval.

Thanking you Sir,

Yours faithfully,

(Dr. Syeda Siddiqua Banu.)

Signature of Guide

Dr. Vidyadhar A Kinhal Professor and Head, Dept of Surgery, VIMS, Bellary.

From, Date: The Professor & Head Bellary. Department of Surgery Vijayanagara Institute of Medical Sciences, Bellary.

To, The Registrar, Rajiv Gandhi University of Health Sciences, Bangalore.

THROUGH PROPER CHANNELSir,

Subject: Submission of synopsis for registration and forwarding.

As per the regulation of the Rajiv Gandhi University of Health Sciences for Registration of dissertation topic, the following Post Graduate student in M.S.(GENERAL SURGERY) has been allotted the dissertation topic as follows by the official registration committee of all qualified and eligible guide of the Department of SURGERY.

NAME TOPIC GUIDE

Dr.Syeda Siddiqua Banu.Department of SURGERY,VIMS, Bellary.

“ A clinical study of intussusception in children at VIMS Bellary”

Dr. Vidyadhar A Kinhal Professor and Head, Department of General Surgery,VIMS, Bellary.

Therefore, I kindly request you to communicate the acceptance of the dissertation topic allotted to

the PG student at an early date.Thanking you Sir,

Yours faithfully

[DR.VIDYADHAR A KINHAL] The Professor & Head, Department of SURGERY,

VIMS, Bellary.